Thermal Ablation and Thermal Ablation Combined With Medical Therapy for Adenomyosis: A Systematic Review and Network Meta-Analysis

OBJECTIVE: This study compares short-term effects of thermal ablation techniques, alone or with medications, on dysmenorrhea, menstrual volume, uterine size, and lesion size post-medication cessation. METHODS: Searches were conducted on PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, VIP, CBM, ClinicalTrials.gov, and the Chinese clinical trial registry until May 11, 2024. We included randomised controlled trials (RCTs) of thermal ablation with medications for adenomyosis, reporting changes in dysmenorrhea, menstrual volume, uterine size, and lesion size at 6 and 12 months post-surgery. Study quality was assessed using the Cochrane risk-of-bias tool (RoB 2) and CINeMA for evidence certainty. A Bayesian network meta-analysis compared intervention efficiencies, with rank probability based on cumulative ranking curve values. RESULTS: The network meta-analysis included 29 trials of 10 treatments. HIFU + Oxytocin + GnRH-a significantly reduced dysmenorrhea at 6 months (SMD = -0.65, 95% CI: -1.1, -0.20), and HIFU + Oxytocin + LNG-IUS at 12 months (SMD = -0.86, 95% CI: -1.7, -0.024), both superior to HIFU alone. HIFU + GnRH-a + LNG-IUS and HIFU + GnRH-a were superior in menstrual flow reduction at 6 and 12 months compared to HIFU, but other comparisons were not significant. HIFU + GnRH-a showed better uterine volume outcomes at 6 months (SMD = -0.19, 95% CI: -0.35, -0.040), and HIFU + Gestrinone at 12 months (SMD = -0.66, 95% CI: -1.3, -0.028). No significant differences were found in lesion size reduction between HIFU combined with medications and HIFU alone. CONCLUSIONS: No single treatment was superior to HIFU in all aspects. Tailored treatments can be based on patient symptoms. Study limitations include small sample sizes. Further studies on long-term efficacy of ablation with drug therapy for adenomyosis are needed.